Community Oncologist

58 yr old female who had been undergoing bariatric surgery evaluation. Screening labs showed elevated protein for which she was referred to me. Workup: SPEP: M-spike of 4.7 grams, IgG 6000, IgG Lambda on SIFE, Free K/L: 10.07/255.37 [ratio of 0.02], renal function and calcium WNL's. PET/CT negative. S/P BM Bx 08/02 with pending results. No baseline neuropathy or cardiac disease. ECOG 0 Question: I typically have been doing front-line RVD in patients however I wanted to ask if you have been using Quadruple therapy such as Dara-RVD. I see that it is listed as an option on NCCN. If so, would that include standard risk patients? Plan to refer her to BMT as well. Any issues with Dara induction therapy for BMT sequencing?

MM Specialist

Looking through this description- how do we know this is myeloma, versus smoldering myeloma? I don't see any evidence of CRAB criteria (you didnt mention Hb), or SLiM criteria (the involved/uninvolved ratio is 25, although you havent gotten a bone marrow biopsy result back yet, or gotten a myeloma MRI). I think the first thing to do would be to confirm it is myeloma versus smoldering. Assuming it is myeloma, Dara-RVD is a very acceptable option. Although long-term outcomes are not available, Dara-RVD is associated with deeper responses and quicker responses- regardless of cytogenetic risk. Use of dara is associated with a slightly lower stem cell yield- but is in no way prohibitive and most patients still collect well for stem cell transplant. If smoldering- this will be high risk smoldering (according to 2/20/20) criteria given the high burden of disease. For these patients, a clinical trial may be an option. Although lenalidomide can be used to prevent progression- and has data from two randomized trials to guide it- the data is conflicting and subject to many limitations- I do not generally use it. Could make a case to watch very closely with monthly labs to assess trajectory and then decide what to do.